BMJ 2012;344:e2333 doi: 10.1136/bmj.

e2333 (Published 26 April 2012) Page 1 of 12

Research

RESEARCH

Effectiveness of a diabetes education and self

management programme (DESMOND) for people with
newly diagnosed type 2 diabetes mellitus: three year
follow-up of a cluster randomised controlled trial in
primary care
OPEN ACCESS

1
Kamlesh Khunti professor of primary care diabetes and vascular medicine , Laura J Gray lecturer
1 2
of population and public health sciences , Timothy Skinner director rural clinical school , Marian E
3 3
Carey national director; DESMOND programme , Kathryn Realf research assistant , Helen Dallosso
3 1
research associate , Harriet Fisher research assistant , Michael Campbell professor of medical
4 5
statistics , Simon Heller professor of clinical diabetes , Melanie J Davies professor in diabetes
6
medicine
1
Department of Health Sciences, University of Leicester, Leicester LE1 6TP, UK; 2Rural Clinical School, University of Tasmania, Tasmania, Australia;
3
Diabetes Research, University Hospitals of Leicester, Leicester, UK; 4Health Services Research, ScHARR, University of Sheffield, Sheffield, UK;
5
Department of Human Metabolism, University of Sheffield, Sheffield, UK; 6Department of Cardiovascular Sciences, University of Leicester

Abstract
Objective To measure whether the benefits of a single education and
self management structured programme for people with newly diagnosed
type 2 diabetes mellitus are sustained at three years.
Design Three year follow-up of a multicentre cluster randomised
controlled trial in primary care, with randomisation at practice level.
Setting 207 general practices in 13 primary care sites in the United
Kingdom.
Participants 731 of the 824 participants included in the original trial
were eligible for follow-up. Biomedical data were collected on 604
(82.6%) and questionnaire data on 513 (70.1%) participants.
Intervention A structured group education programme for six hours
delivered in the community by two trained healthcare professional
educators compared with usual care.
Main outcome measures The primary outcome was glycated
haemoglobin (HbA1c) levels. The secondary outcomes were blood
pressure, weight, blood lipid levels, smoking status, physical activity,
quality of life, beliefs about illness, depression, emotional impact of
diabetes, and drug use at three years.
Results HbA1c levels at three years had decreased in both groups. After
adjusting for baseline and cluster the difference was not significant
(difference 0.02, 95% confidence interval 0.22 to 0.17). The groups
did not differ for the other biomedical and lifestyle outcomes and drug
use. The significant benefits in the intervention group across four out of
five health beliefs seen at 12 months were sustained at three years
(P<0.01). Depression scores and quality of life did not differ at three
years.
Conclusion A single programme for people with newly diagnosed type
2 diabetes mellitus showed no difference in biomedical or lifestyle
outcomes at three years although there were sustained improvements
in some illness beliefs.
Trial registration Current Controlled Trials ISRCTN17844016.
Introduction
Type 2 diabetes mellitus is a serious, progressive condition
presenting with chronic hyperglycaemia, and its prevalence is
increasing globally. In the short term, type 2 diabetes may lead
to symptoms and debility and in the long term to serious
complications, including blindness, renal failure, and
amputation.1 Furthermore, three quarters of people with type 2

Correspondence to: K Khunti kk22@le.ac.uk

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Quality of life data at three years

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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012)
diabetes will die from cardiovascular disease.2 Traditionally,
treatment for the condition has centred on drug interventions to
stabilise hyperglycaemia and to manage cardiovascular risk
factors, including blood pressure and lipids, to prevent associated
symptoms and reduce the risk of vascular complications over
time.3 Long term follow-up data from the United Kingdom
Prospective Diabetes Study has shown that despite early
successes, metabolic control progressively worsens with time,
warranting exploration of alternative approaches for long term
management of type 2 diabetes.4
Anyone with diabetes, including type 2 diabetes, has to make
multiple daily choices about the management of their condition,
such as appropriate dietary intake, physical activity, and
adherence to drugs, often with minimal input from a healthcare
professional.5 In recent years, programmes to educate people
about self management have become the focus of attention
among healthcare professionals and are advocated for people
with type 2 diabetes as a means to acquire the skills necessary
for active responsibility in the day to day self management of
their condition.6-10 In addition, it has been suggested that
education on self management may play a pivotal role in tackling
beliefs about health and so improve metabolic control,
concordance with drug decisions, risk factors, and quality of
life.11-13
Globally, self management education is recognised as an
important component for the management of type 2 diabetes;
the American Diabetes Association states that it should be
offered from the point of diagnosis.14 Similarly in the United
Kingdom, where this study was undertaken, the 2008 National
Institute for Health and Clinical Excellence guidelines for
diabetes,15 national service framework for diabetes,9 and the
2011 quality standards from NICE, advocate the provision of
self management education from diagnosis. The diabetes
education and self management for ongoing and newly
diagnosed (DESMOND) intervention was one of the first
programmes to meet the quality criteria for education
programmes that are listed by the Department of Health and
Diabetes UK Patient Working Group, which are consistent with
the American Diabetes Association criteria.16 DESMOND is
currently available in 103 health organisations across the United
Kingdom, Republic of Ireland, Gibraltar, and Australia, with
735 trained educators.
The study design, baseline characteristics of the participants,
and changes in biomedical, lifestyle, and psychosocial measures
at 12 months have been reported and showed improvements in
weight, smoking cessation, illness beliefs, depression, and
cardiovascular risk scores in participants who received the
intervention compared with standard care.17-19 The programme
has recently been shown to be cost effective.20
Few self management education programmes have reported
long term effects of the intervention.21 Self management
education programmes, such as DESMOND, may incur benefits
to participants in the longer term, as participants who
successfully acquire, embrace, and maintain the necessary skills
for the self management of their condition may gain further
benefits in terms of biomedical and psychosocial outcomes. We
evaluated whether the impact of a single structured self
management education programme (DESMOND) with six hours
contact time within six weeks of diagnosis was sustained at
three years.
Methods
The study methods, intervention, and outcomes at 12 months
have been reported in detail previously.18 19 Briefly, a robust
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Page 2 of 12
RESEARCH
cluster randomised controlled trial was undertaken to assess the
effectiveness of a structured self management education
programme that took place in 13 primary care sites (207
practices) across England and Scotland. Randomisation took
place at the level of the general practice to minimise
contamination between participants, with stratification by
training status and type of contract with the primary care
organisation (General Medical Services or Personal Medical
Services). Randomisation was undertaken independently at the
University of Sheffield using Random Log. At each site a local
coordinator oversaw the trial, recruited and trained practices,
and maintained contact with practice staff. Performance of the
sites and local coordinators was monitored regularly, with each
site receiving a visit before the trial and a minimum of one
monitoring visit per year. Practice staff sent biomedical data to
the local coordinator for forwarding to the central coordinating
centre.
Individuals were referred within six weeks of diagnosis to the
study, with those in the intervention arm attending a structured
education programme within 12 weeks of diagnosis. Participants
in the original trial were excluded if they were aged less than
18 years, had severe and enduring mental health problems, were
not primarily responsible for their own care, were unable to
participate in a group programme (for example, were
housebound or unable to communicate in English), or were
participating in another research study. Recruitment took place
between October 2004 and January 2006. Everyone who
consented to join the original trial was eligible for follow-up at
three years unless they had withdrawn during the trial or their
practice informed us they were no longer at the practice or that
it would be inappropriate to contact them (for example, owing
to serious illness).
The intervention
The structured group education programme is based on a series
of psychological theories of learning: Leventhals common
sense theory,22 dual process theory,23 and social learning theory.24
The philosophy of the programme was founded on patient
empowerment, as evidenced in published work.25 26
The intervention was devised as a group education programme,
with a written curriculum suitable for a wide range of
participants, delivered in a community setting, and integrated
into routine care. Registered healthcare professionals received
formal training to deliver the programme and were supported
by a quality assurance component of internal and external
assessment to ensure consistency of delivery. The programme
was six hours long, deliverable in either one full day or two half
day equivalents, and facilitated by two educators. Learning was
elicited rather than taught, with the behaviour of the educators
promoting a non-didactic approach. Most of the curriculum
focused on lifestyle factors, such as food choices, physical
activity, and cardiovascular risk factors. The programme
activates participants to consider their own personal risk factors
and, in keeping with theories of self efficacy, to choose a
specific achievable goal to work on.24 The broad content of the
curriculum and an overview of the quality assurance have been
reported elsewhere.17
The methods followed for the present study were similar to
those of the original trial. Participants were sent a postal
questionnaire two weeks before the three year follow-up date.
A reminder letter and further copy of the questionnaire were
sent if the original questionnaire was not returned within three
weeks. Practices were contacted at the same time and asked to
forward the most recent biomedical measurements on the
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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012)
participants to see if differences to biomedical and psychosocial
outcomes could be sustained at three years. Given the nature of
the original intervention, the study was not blinded.
Outcome variables
Follow-up took place at four, eight, and 12 months and at three
years, with biomedical, lifestyle, and psychosocial data being
collected. Biomedical outcomes included glycated haemoglobin
(HbA1c) level, blood pressure, levels of total cholesterol, high
density lipoprotein cholesterol, low density cholesterol, and
triglycerides, body weight, and waist circumference.
Questionnaires (described in detail in18) included lifestyle
questions on smoking status and physical activity, as well as
quality of life and health related quality of life. We used an
illness perceptions questionnaire27 to assess peoples perception
that they understood their diabetes (coherence), perception of
the duration of their illness (timeline), and perception of their
ability to affect the course of their diabetes (personal control).
In addition, we collected data on perceived seriousness and
perceived impact of diabetes, emotional distress specific to
diabetes using the problem areas in diabetes questionnaire,28
and depression.
Statistical analysis
For the original study the sample size was calculated on the
basis of a standard deviation of HbA1c levels of 2%, an intraclass
correlation of 0.05, and an average of 18 participants per
practice. We calculated that we needed 315 participants per
study arm to detect a clinically relevant difference in HbA1c
levels of 1% at 12 months, with 90% power at the 5%
significance level. Assuming a failure to consent rate of 20%
(not eligible as well as declining to participate) and a dropout
rate of 20%, 1000 participants (500 in each arm) needed to be
referred.
Statistical analysis was carried out by intention to treat.
Continuous variables are given as means and standard deviations
or medians and interquartile ranges and categorical variables
as counts and percentages. To adjust for cluster we used robust
generalised estimating equations with an exchangeable
correlation structure. For binary outcomes we used a logit link
with a binomial distribution for the outcome, and for continuous
outcomes we used an identity link with a normal distribution.
Adjustment for baseline value was made in all models (apart
from the problem areas in diabetes score, which was not
recorded at baseline as it was inappropriate for participants with
newly diagnosed type 2 diabetes). We assumed data to be
missing completely at random and they were not replaced or
imputed. Statistical significance was set at 5%, with no
adjustment for multiple testing, although all P values were
interpreted in line with the pattern of the results. All analysis
was carried out in Stata (version 10.0).
Results
Of the 824 individuals who consented to take part from the 207
general practices (387 control and 437 intervention) to the
original trial, 743 (90.2%) were eligible for follow-up at three
years. Of those not eligible, 26 died, 44 withdrew from the study,
16 moved practice, and seven were identified by practices as
being too ill to follow up (figure). Biomedical data were
collected on 604 (82.6%) of those eligible. Biomedical data was
provided for 332 (85.6%) participants in the intervention arm
and 272 (79.3%) in the control arm. Postal questionnaires were
completed by 536 (73.1%) of those eligible. The level of return
for the questionnaires was 299 (75.3%) for the intervention arm
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RESEARCH
and 237 (68.5%) for the control arm. Table 1 compares the
baseline characteristics of those who were and were not
successfully followed up at three years. The group on whom
three year follow-up data were obtained were older (P=0.01)
and had a lower weight (P=0.004), body mass index (P=0.004),
waist circumference (P<0.001), and depression score (P<0.001).
When taking into account the treatment group, no interactions
between responders and group were found for these outcomes.
Biomedical outcomes
Table 2 shows the mean (95% confidence interval) change in
biomedical outcomes in the study groups at three years. Across
all biomedical outcomes improvements were seen in both
groups, with no significant differences between groups at three
years. The primary outcome, HbA1c level, did not differ
significantly between the groups. The observed difference
between intervention groups was 0.02 (95% confidence interval
0.22 to 0.17) after adjusting for baseline and clustering. The
intraclass correlation for HbA1c at three years was 0.02 (95%
confidence interval 0.00 to 0.08).
At three years, no statistical difference was seen in 10 year
coronary heart disease or cardiovascular risk (United Kingdom
Prospective Diabetes Study) between the intervention and
control groups, with reductions observed in both groups (table
2).
Lifestyle outcomes
A significant difference in the proportion of non-smokers was
seen in favour of the intervention arm at 12 months. This
difference was not maintained at three years. No difference in
the level of physical activity between the groups was seen at
three years (P=0.58, table 3).
Illness beliefs, depression, problem areas in
diabetes, and quality of life
Table 4 shows the results for the psychosocial measures. After
adjustment for baseline value and cluster, four of the five illness
belief scores (coherence, timeline, personal responsibility, and
seriousness) differed significantly at three years. The
intervention participants had higher scores for all, showing that
they had a greater understanding of their illness and its
seriousness and a better perception of the duration of their
diabetes and of their ability to affect the course of their disease.
No difference was seen between the groups for depression,
problem areas in diabetes scores, and quality of life at three
years (see supplementary file on bmj.com for quality of life
data).
Drugs
At three years the number of people taking oral antidiabetic
agents as monotherapy or dual therapy or those taking insulin
did not differ significantly between the groups (table 5).
Discussion
After three years the impact of a single structured education
intervention delivered to people with newly diagnosed type 2
diabetes mellitus was not sustained for biomedical and lifestyle
outcomes, although some changes in illness beliefs were still
apparent.
Previously we reported that compared with baseline at 12
months HbA1c levels decreased by 1.49% (95% confidence
intervals 1.69% to 1.29%) in the intervention group and by
1.21% (1.40% to 1.02%) in the control group.18 The present
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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012)
study showed a small increase in HbA1c levels from the 12 month
data; however, overall the decreases in both the intervention
group (1.32%, 1.57% to 1.06%) and the control group
(0.81%, 1.02% to 0.59%) were sustained at three years.
Although this is reassuring compared with the long term
follow-up results of the United Kingdom Prospective Diabetes
Study, which reported a 1% increase in HbA1c level over four
years in a newly diagnosed cohort,4 this is not entirely
unexpected in the context of the recent improvements to the
management and quality of care of type 2 diabetes after the
introduction of the quality outcomes framework.29 A pragmatic,
cluster randomised study undertaken in primary care,
ADDITION-Europe, was unable to detect cardiovascular benefit
of multifactorial therapy compared with routine care in people
with type 2 diabetes detected by screening. This is thought to
be at least in part attributable to changes to national guidelines
during the follow-up period of the trial, resulting in allocated
treatments of the intervention and control group becoming more
similar.30 The clear benefits of an intervention above routine
care has become increasingly difficult to show in a setting where
outcome measures are often successfully treated to target from
diagnosis. However, other important aspects of diabetes
management are not currently captured or incentivised by current
targets, including self management skills and empowerment,
which were evaluated in this study.29
A report of the best methods for evaluating diabetes education
identified four key outcomes associated with optimal adjustment
to living with diabetes, which comprised knowledge and
understanding, self management, self determination, and
psychological adjustment, two of which were assessed in this
study.31 The significant improvements to four of the five illness
beliefs were sustained at three years and indicate a greater
understanding by the participants of their diabetes and of their
ability to affect the course of their diabetes. Although
participants from the intervention group believed their diabetes
to be more serious and were more likely to agree that they would
have diabetes for life, this had not caused them greater distress
about their diabetes, as evidenced by responses to the problem
areas in diabetes questionnaire. Further research is required to
ascertain how to translate these into favourable biomedical
outcomes in the longer term.
Since the launch of the DESMOND programme, numerous
studies have aimed to improve self management in people with
type 2 diabetes. A recent meta-analysis assessing the impact of
self management interventions in people with type 2 diabetes
published before 2007 reported improvements to glycaemic
control in people who received self management treatment, with
a small advantage of an intervention with an educational
approach.21 The results of the DESMOND intervention published
in 2008 were not included in the meta-analysis. Of the studies
included in the review, only eight reported follow-up results at
greater than 12 months.
The DESMOND intervention for people with newly diagnosed
type 2 diabetes was always intended to be included within an
ongoing model of education and clinical care, integrating life
long learning, care planning, and treatment optimisation.
However, a key aspect of the study design was to show at what
point any benefits of intervention begin to diminish. Currently,
our group are developing and implementing the DESMOND
ongoing module to evaluate the long term effectiveness of an
ongoing self management intervention in people with type 2
diabetes. The findings of these studies will help to determine
the optimal contact time and frequency of education sessions
required to sustain improvements to clinical outcomes through
self management. The DESMOND intervention is likely to
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Page 4 of 12
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remain cost effective as the cost effectiveness analysis of the
DESMOND intervention using 12 month data was based on the
assumption that observed lifestyle changes and smoking
cessation would not be sustained without an ongoing
maintenance intervention.20 We have shown that delivery of the
DESMOND intervention at diagnosis is beneficial for
psychosocial outcomes. Although these benefits are important
it remains uncertain at what stage, if ever, biomedical benefits
emerge in people with newly diagnosed type 2 diabetes and
whether in the longer term a relation between the two translates
into more effective self management to maintain glycaemic
control. Participants may need further education and ongoing
support to successfully manage their condition and to achieve
improvements to clinical outcomes and self management
behaviours long term.
Comparison with other studies
Evidence of the long term impact of structured education
interventions in people with diabetes is currently lacking. The
dose adjustment for normal eating (DAFNE) intervention
delivered as a single structured education programme to a group
of adults with type 1 diabetes showed clinically significant
improvements to HbA1c levels without an increase in severe
hypoglycaemia at two years.32 Quality of life and improvements
to HbA1c levels were maintained at four years.33 The authors
suggest that follow-up support for this population group may
create additional benefits by helping people to identify routines
to better integrate this regimen into their lives.
The expert patient education versus routine treatment (X-PERT)
programme reported significant improvements to HbA1c level
at 14 months (0.6% v 0.1%) in a population with established
type 2 diabetes, although long term results have not yet been
reported.34 Participants of the X-PERT programme had a mean
duration of 6.7 years, compared with our newly diagnosed cohort
in whom additional benefits of an education programme were
hard to show when medical outcomes were aggressively and
successfully targeted. An additional dissimilarity is that the
X-PERT intervention was delivered over six sessions with
participants receiving double the contact time as those of the
DESMOND intervention, which may confer additional benefits.
The rethink organisation to improve education and outcomes
(ROMEO) intervention was delivered in a secondary care clinic
setting in Italy as a continuous education programme. Long
term outcomes at four years have reported favourable clinical,
cognitive, and psychological outcomes in a cohort with
established type 2 diabetes.35 The intervention comprised one
hour education sessions delivered on a three monthly basis,
whereas the DESMOND module was delivered as a single
intervention involving six hours of contact time, with no further
reinforcement of the messages delivered. The ROMEO
intervention implies that an ongoing model of education and
care can result in improvements to clinical outcomes. However,
further research is required to ascertain whether these results
are replicable out of the Italian secondary care clinical setting.
A self management intervention delivered in a primary care
setting in Sweden showed an adjusted difference in HbA1c level
of 1.37% (P<0.001) at five years between intervention and
control groups.36 The intervention group received 10 group
sessions, two hours long, over a period of nine months. The
intervention did not have a curriculum or agenda, and whether
the impressive study results can be replicated has yet to be
determined.
As with all educational interventions, DESMOND is a complex
intervention, which makes it difficult to ascertain the active
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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012)
components contributing to positive effects of the intervention.37
One aspect of the DESMOND intervention is goal setting, where
the participant chooses one part of their care to work at. The
relative success of this component, as with others, is currently
unknown in the DESMOND intervention. A randomised
controlled trial that evaluated the impact of goal setting in self
management education in people with type 2 diabetes recently
reported that at 12 months statistically significant favourable
differences in HbA1c levels were seen in the intervention group.38
Strengths and limitations of the study
The original DESMOND trial has several strengths, which have
been discussed at length previously.18 In brief, the trial had a
robust cluster randomised design, with reasonably well matched
participants in the control and intervention groups, and the study
was successful in minimising contamination between practices.
Importantly, the intervention was designed for consistent
reproducibility of training and had a relatively low up-front
training investment, enabling implementation across other sites.
All educators participating in the intervention were fully trained
and quality assured, ensuring generalisability of the findings in
other DESMOND studies and out of the research setting.
Statistical analyses for this study were undertaken using
intention to treat analysis, minimising bias in the reported
findings. However, our study may have been underpowered to
detect improvements in clinical outcomes and as a result some
of our findings may be prone to type 2 error. Response rates of
the study were higher than expected after three years of
follow-up, with collection of biomedical data achieved by 83%
of participants and questionnaire data by 70%, minimising
missing data and the effect this may have had on the
interpretation of the study results. This compares positively with
other self management education interventions that obtained
long term follow-up data from 63% to 85% of the original
participants.33 35 36 Those who were followed up at three years
were older, healthier, and less depressed at baseline than those
who were not followed up. This selection bias should be
considered when interpreting the results, although importantly
there was no interaction with intervention group. Additionally,
missing data on individuals may have less impact in a cluster
randomised trial than in an individually randomised trial.
A weakness of our study was lack of power to find differences
in hard end points and that significant differences in mortality
or cardiovascular events were unlikely to be detected in this
study. In reality, intervention studies that report decreases in
cardiovascular mortality and morbidity in people with type 2
diabetes require longer follow-up.39 40 Studies designed with
sufficient power to detect differences in these important
outcomes will provide valuable information to shape the model
of future diabetes care. A non-response bias was detected in
this study, with responders being older, less overweight
(according to body mass index and waist circumference), and
reporting more depressive symptoms.
Conclusion
In a cohort of adults with newly diagnosed type 2 diabetes a
single, six hour structured programme in self management did
not offer sustained benefits in biomedical outcome measures
and lifestyle outcomes at three years, but some changes to illness
beliefs were sustained. The results support a programme of an
ongoing model of education, although the optimum interval and
contact time needs further evaluation. However, we recognise
that additional support through increased contact time and
frequency may incur additional benefit through important
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Page 5 of 12
RESEARCH
improvements to biomedical outcomes, and further research to
establish this is needed. Future studies need to incorporate a
longer follow-up period to generate understanding of
intervention effects over time.
We thank the National Institute for Health Research Collaboration for
Leadership in Applied Health Research and CareLeicestershire,
Northamptonshire, and Rutland, and the Biomedical Research Unit.
Contributors: KK was the principal investigator of the three year follow-up
study and drafted the paper. LG analysed the data and drafted the
paper. TCS was involved in the conception of the DESMOND
programme and reviewed the paper. MEC was the project manager of
the 12 months DESMOND trial and reviewed the paper. KR collated
the data. HD was senior researcher and collated data and drafted the
paper. HF drafted the paper. MC was involved in the design, analysis,
and interpretation of the data. SH was involved in the conception of the
DESMOND programme and reviewed the paper. MJD was the principal
investigator for the DESMOND trial, designed the trial, and reviewed
the paper.
Funding: This study was funded by a grant from Diabetes UK secured
by a joint team from Leicester University and the University Hospitals
of Leicester NHS Trust. The writing of the report and the decision to
submit the article for publication was entirely independent of the funder.
The study funder had no input into the study design or analysis, nor the
interpretation of data.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: no support from
any company for the submitted work; no financial relationships with any
companies that might have an interest in the submitted work in the
previous three years; no other relationships or activities that could appear
to have influenced the submitted work.
Ethical approval: This study was approved by the Huntingdon local
research ethics committee and was carried out in accordance with the
principles of the 1996 Helsinki declaration.
Data sharing: No additional data available.
1 Massi-Benedetti M. The cost of diabetes type ii in Europe: the CODE-2 study. Diabetologia
2002;45:S1-4.
2 Tapp R, Shaw J, Zimmet P, eds. Complications of diabetes. In: International diabetes
federation, ed. Diabetes atlas. 2nd ed.International Diabetes Federation, 2003.
3 Norris S, Nichols P, Caspersen C, Glasgow R, Engelgau M, Jack L. Increasing diabetes
self management education in community settings. A systematic review. Am J Prev Med
2002;22:39-66.
4 UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas
or insulin compared with conventional treatment and risk of complications in patients with
type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.
5 Jarvis J, Skinner T, Carey M, Davies M. How can structured self-management patient
education improve outcomes in people with type 2 diabetes? Diabet Obes Metab
2010;12:12-9.
6 Rutten G. Diabetes patient education: time for a new era. Diabet Med 2005;22:671.
7 National Institute for Health and Clinical Excellence. Guidance on the use of patient
education models for diabetes (technology appraisal 60). NICE, 2003.
8 Department of Health. National service framework for diabetes: delivery strategy.
9
Department of Health, 2002.
Department of Health. National service framework for diabetes: standards. Department
of Health, 2001.
10 Audit Commission. Testing times. A review of diabetes services in England and Wales.
Belmont Press, 2000.
11 Norris S, Lau J, Smith S, Schmid C, Engelgau M. Self management education for adults
with type 2 diabetes: a meta analysis of the effect on glycemic control. Diabetes Care
2002;25:1159-71.
12 Skinner T, Cradock S, Arundel F, Graham W. Four theories and a philosophy: self
management education for individuals newly diagnosed with type 2 diabetes. Diabetes
Spectrum 2003;16:75-80.
13 Lorig K. Partnerships between expert patients and physicians. Lancet 2002;359:814-5.
14 American Diabetes Association. Position statement: standards in diabetes care. Diabetes
Care 2010;33:S11-61.
15 National Institute for Health and Clinical Excellence Guidance 87. Type 2 diabetes: the
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management of type 2 diabetes (partial update). NICE, 2009.
Department of Health, Diabetes UK. Structured patient education in diabetes: report from
the Patient Education Working Group. Department of Health, 2005.
17 Skinner T, Carey M, Cradock S, Daly H, Davies M, Doherty Y, et al. Diabetes education
and self-management for ongoing and newly diagnosed (DESMOND): process modelling
of pilot study. Patient Educ Couns 2006;64:369-77.
18 Davies M, Heller S, Skinner T, Campbell M, Carey M, Cradock S, et al, on behalf of the
Diabetes Education and Self Management for Ongoing and Newly Diagnosed Collaborative.
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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012) Page 6 of 12

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What is already known on this topic

The diabetes national service framework and NICE quality standards promote structured education for all from diagnosis of diabetes
Until now no studies have evaluated the long term impact of attending an education intervention

What this study adds

Differences in biomedical and lifestyle outcomes at 12 months from a structured group education programme for patients with newly
diagnosed type 2 diabetes were not sustained at three years, although illness beliefs remained significant
The results support the model of an ongoing education programme, although the optimum interval and contact time needs further
evaluation

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Accepted: 1 March 2012
Cite this as: BMJ 2012;344:e2333
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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012) Page 7 of 12

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Tables

Table 1| Baseline characteristics of participants with type 2 diabetes who were or were not followed up at three years. Values are means
(standard deviations) unless stated otherwise

Not followed up at 3 years Followed up at 3 years P values

Not followed
Intervention Intervention up v Group
Characteristics Total (n=220) (n=105) Control (n=115) Total (n=604) (n=332) Control (n=272) responders interaction
Age (years) 57.6 (12.5) 57.8 (12.9) 57.5 (12.2) 60.1 (11.8) 59.4 (11.6) 61.01 (12.1) 0.01 0.31
No (%) female 101 (45.9) 53 (50.5) 48 (41.7) 271 (44.9) 151 (45.5) 120 (44.1) 0.79 0.35
No (%) white European
ethnicity 182 (95.3) 91 (95.8) 91 (94.8) 543 (97.1) 307 (97.2) 236 (97.1) 0.22 0.81
No (%) smokers 34 (17.9) 15 (16.0) 19 (19.8) 76 (13.6) 42 (13.3) 34 (14.1) 0.15 0.68
HbA1c (%) 8.3 (2.2) 8.3 (2.2) 8.1 (2.1) 8.0 (2.1) 8.3 (2.2) 7.7 (1.9) 0.31 0.27
Total cholesterol (mmol/L) 5.4 (1.3) 5.3 (1.3) 5.5 (1.3) 5.3 (1.3) 5.4 (1.4) 5.3 (1.2) 0.58 0.12
High density lipoprotein
cholesterol (mmol/L) 1.2 (0.4) 1.2 (0.4) 1.2 (0.5) 1.2 (0.4) 1.2 (0.5) 1.2 (0.3) 0.86 0.29
Low density lipoprotein
cholesterol (mmol/L) 3.3 (1.2) 3.0 (1.0) 3.5 (1.3) 3.2 (1.1) 3.2 (1.1) 3.2 (1.0) 0.55 0.03
Triglycerides (mmol/L) 2.6 (2.0) 2.3 (1.8) 3.0 (2.1) 2.5 (2.1) 2.7 (2.6) 2.3 (1.4) 0.49 0.002
Systolic blood pressure
(mm Hg) 140.3 (19.0) 142.1 (19.5) 138.6 (18.3) 140.6 (17.1) 140.7 (18.1) 140.5 (15.9) 0.81 0.23
Diastolic blood pressure
(mm Hg) 82.3 (11.0) 83.0 (10.7) 81.6 (10.4) 81.6 (10.4) 82.3 (10.5) 80.7 (10.2) 0.39 0.98
Body weight (kg) 95.0 (22.1) 93.7 (21.6) 96.2 (22.5) 90.5 (18.6) 91.2 (18.3) 89.7 (18.9) 0.004 0.2
Body mass index 33.4 (6.7) 33.0 (6.4) 33.8 (7.0) 32.0 (6.0) 32.1 (5.9) 31.8 (6.1) 0.004 0.3
Waist circumference (cm) 108.4 (14.6) 108.5 (14.8) 108.3 (14.5) 105.3 (13.9) 104.8 (14.6) 105.9 (13.1) 0.008 0.59
Illness beliefs:
Coherence score 14.5 (4.2) 14.8 (4.3) 14.2 (4.3) 15.0 (4.2) 14.5 (4.1) 15.8 (4.2) 0.12 0.01
Timeline score 19.7 (3.7) 20.2 (3.6) 19.3 (3.8) 20.1 (4.0) 20.4 (3.9) 19.6 (4.1) 0.31 0.94
Responsibility score 23.9 (3.5) 23.8 (3.0) 24.0 (4.0) 24.4 (3.2) 24.4 (3.4) 24.5 (3.0) 0.06 0.93
Seriousness score 16.6 (2.4) 16.7 (2.4) 16.5 (2.3) 16.5 (2.7) 16.4 (2.7) 16.6 (2.7) 0.53 0.99
Impact score 14.8 (3.9) 14.8 (3.0) 14.8 (4.2) 14.2 (3.4) 14.1 (3.4) 14.4 (3.7) 0.05 0.75
HADS depression score 4.4 (3.7) 4.1 (3.4) 4.6 (4.0) 3.3 (3.3) 3.2 (3.1) 3.4 (3.1) <0.001 0.59

HADS=hospital anxiety and depression scale.

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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012) Page 8 of 12

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Table 2| Changes in biomedical outcomes at three years

Change (95% CI)

Model summary, coefficient
Variables No (%) of participants Intervention group Control group (95% CI) P value
HbA1c (%) 585 (96.9) 1.32 (1.57 to 1.06) 0.81 (1.02 to 0.50) 0.02 (0.22 to 0.17) 0.81
Body weight (kg) 592 (98.0) 1.75 (2.48 to 1.03) 1.44 (2.42 to 0.45) 0.20 (1.33 to 0.93) 0.73
Total cholesterol (mmol/L) 589 (97.5) 1.20 (1.35 to 1.05) 1.07 (1.22 to 0.91) 0.03 (0.19 to 0.12) 0.68
High density lipoprotein cholesterol 367 (60.8) 0.01 (0.002 to 0.11) 0.07 (0.03 to 0.11) 0.02 (0.04 to 0.09) 0.51
(mmol/L)
Low density lipoprotein cholesterol 248 (41.1) 0.92 (1.12 to 0.72) 0.84 (1.05 to 0.63) 0.08 (0.28 to 0.13) 0.47
(mmol/L)
Triglyceride (mmol/L) 490 (81.1) 0.37 (0.94 to 0.40) 0.37 (0.56 to 0.18) 0.06 (0.27 to 0.15) 0.56
Systolic blood pressure (mm Hg) 595 (98.5) 7.88 (10.15 to 5.62) 6.58 (8.65 to 4.52) 1.07 (3.42 to 1.28) 0.37
Diastolic blood pressure (mm Hg) 595 (98.5) 6.03 (7.27 to 4.79) 4.45 (5.81 to 3.10) 0.68 (2.20 to 0.83) 0.38
Waist circumference (cm) 264 (43.7) 1.03 (2.43 to 0.37) 0.96 (3.62 to 1.70) 0.38 (4.43 to 3.66) 0.85
Body mass index 586 (97.0) 0.61 (0.87 to 0.36) 0.54 (0.90 to 0.18) 0.03 (0.45 to 0.39) 0.88
UKPDS 10 year coronary heart disease 322 (53.3) 7.80 (9.80 to 5.80) 6.49 (8.62 to 4.36) 1.67 (3.91 to 0.57) 0.14
risk
UKPDS 10 year cardiovascular disease 322 (53.3) 5.91 (8.10 to 3.72) 4.42 (6.89 to 1.95) 1.89 (5.17 to 1.39) 0.26
risk

UKPDS=United Kingdom Prospective Diabetes Study.

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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012) Page 9 of 12

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Table 3| Summary of lifestyle outcomes at three years

Variables No (%) of participants Intervention group Control group Odds ratio (95% CI) P value
Non-smoker 457 (85.3) 253 (91.0) 183 (86.7) 2.07 (0.76 to 5.66) 0.16
Any level of physical activity 419 (78.2) 236 (92.9) 197 (91.2) 1.22 (0.60 to 2.48) 0.58

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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012) Page 10 of 12

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Table 4| Scores for illness beliefs and hospital anxiety and depression scale

Median (interquartile range)

Variables No (%) of participants Intervention group Control group Model summary, coefficient (95% CI) P value
Illness coherence 409 (76.3) 20 (16-20) 19 (15-20) 0.93 (0.20 to 1.65) 0.01
Timeline 414 (77.2) 22 (20-25) 20 (19-25) 0.87 (0.24 to 1.49) 0.01
Personal responsibility 412 (76.9) 24 (23-27) 24 (23-26) 0.49 (0.004 to 0.99) 0.005
Impact 413 (77.1) 13 (12-15) 13 (12-15) 0.22 (0.33 to 0.77) 0.44
Seriousness 414 (77.2) 17 (15-19) 16 (15-18) 0.77 (0.23 to 1.30) 0.01
Depression 465 (86.8) 2 (1-5) 2 (1-6) 0.29 (0.74 to 0.15) 0.19
Problem areas in diabetes scale 461 (86.0) 10.0 (3.8-20.0) 8.8 (2.5-21.3) 0.69 (3.45 to 2.07) 0.63

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BMJ 2012;344:e2333 doi: 10.1136/bmj.e2333 (Published 26 April 2012) Page 11 of 12

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Table 5| Drugs used by participants with type 2 diabetes

Drugs Intervention group Control group P value

Antihypertensives 235 (70.8) 206 (76.9) 0.09
Lipid lowering 266 (80.1) 209 (78.0) 0.52
Antidepressants 24 (8.9) 18 (9.2) 0.90
Oral antidiabetics:
Monotherapy 188 (56.6) 107 (39.3) 0.32
Dual therapy 59 (17.8) 45 (16.5) 0.69
Insulin 10 (3.0) 7 (2.6) 0.75

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Figure

Flow of participants through trial

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